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By: Dr. Elizabeth Craig | April 1, 2015

When it comes to dental insurance there are so many clauses, limitations and exclusions that it would be impossible to cover all of them, but I will attempt to touch on a few of the topics that come up most often in our office.

Many dental plans have an “Alternate Benefit Clause” and in insurance terminology they will provide benefits based on “the least expensive professionally acceptable benefit”. If you are not a dental insurance underwriter that can be very difficult to understand, so let me explain. What they are saying is there is more than one acceptable treatment for a cavity, you may elect a white or silver filling, both would serve the purpose of restoring the tooth. If the insurance company has the “Alternate Benefit Clause” they are saying they are going to pay the benefit for the less costly of the two fillings, regardless of which one you choose. So if you choose a white filling on a back tooth, molar and sometimes premolar, you insurance will pay a benefit equal to that of the silver filling. The patient would then be responsible for the difference in cost in addition to any co-insurance amounts.

Dental maximums

Most dental plans have a maximum dollar amount they will pay within a predetermined period of time. Most often that period of time is a calendar year however that can vary depending on your plan so always consult your plan booklet for specific plan information. For the sake of the following we will assume the plan I am talking about is based on a calendar year.

The maximum is the total dollar amount your insurance will pay for dental treatment within a calendar year. Keep in mind that all payments will be subject to deductible and coinsurance if applicable. This included payments made to your general dentist, oral surgeon, periodontist, endodontist or any other dental care provider you visit.

Proposed treatment plans

When you are seen in our office we give you a proposed treatment plan, this will include cost and our estimate of your dental benefits based on the information we have gathered from your insurance company. This is simply an estimate and by no way a guarantee of benefits. We are able to get a better idea of what your insurance will pay by sending a pre-authorization to your insurance company for review. This will give us a far better idea of what your insurance will pay however, this is still not a guarantee of benefits as the claim will be based on the benefits, maximum and deductible available on the date of service.

What if I still have questions?

You are always welcome to come to us with any dental insurance questions you have, we will do our best to answer them for you. Your dental insurance company, your dental plan booklet and your Human Resources department are also great ways to gather information about your dental insurance. Please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss this with your human resources department to explore other options that may be available to you.